optic neuritis and multiple sclerosis

Question 1

Optic neuritis:

Answer 1

Common inflammatory disease:
optic nerve

Vision recovery :
a single episode without treatment
visual acuity improves - 2-3 weeks

isolated optic neuritis:
probability of multiple sclerosis:
MRI with two or more plaques
consider treatment

Acute stage:
Normal optic nerve 2/3 cases

Late-stage swollen optic disc = papillitis
papillary hemorrhages

Question 2

Optic Nerutis assessement

Answer 2

pain behind eye: exacerbated by movements

field of vision loss: central, loss of color vision

Severe form : neuromyelitis Optica , extensive bilateral

Question 3

Treatment of optic Neuritis

Answer 3

high dose methylprednisolone :
1 gm QD x 3 days
250 Q 6h IV
prednisone taper

Question 4

multiple Sclerosis Disease

Answer 4

Autoimmune disease:
affects CNS
relapsing or progressive
plaques develop at different times and in different CNS locations

Question 5

Multiple sclerosis findings:

Answer 5

chronic inflammation
demyelination
gliosis
neuronal loss

Question 6

multiple sclerosis clinical course

Answer 6

extremely variable
benign condition incapacitating disease

Question 7

Risk factors for multiple sclerosis

Answer 7

more common in women
age of onset 20-40
genetic predispotion
vit D deficiency
EBV
cigeratte smoking

Question 8

Multiple Sclerosis clinical findings:

Answer 8

paresthesia and hypoesthesia: pain associated > 50%

optic neuritis: diminished visual acuity

Fatigue : most common reason for work related disability

weakness of limbs: loss of strength, speed dexterity or fatigue , exercise-induced weakness

Facial weakness resembling bells palsy :
No loss of taste sensation

spasticity :
spontaneous and movement induced
> 30% have moderate to severe spasticity of legs

Ataxia: can involve the head and trunk, characteristic cerebellar dysarthria

visual blurring or double vision:vertigo with brain stem lesion

Question 9

multiple sclerosis clinical findings continued

Answer 9

paroxysmal symptoms: brief duration (10sec to 2 min
high frequency 5-40 episodes per day, no altered LOC
precipitated by hyperventilation or movement

Lhermitte’s symptom is an electrical shock sensation that radiates back into the legs.
;
trigeminal nerualgia: lesion involves 5th CN, uncontrollable stun like pain

Hemifacial spasm: lesion involves 7th CN

Glossopharyngeal neuralgia: lesion involves the 9th cranial nerve, pain in oral perennial area

balder dysfunction: frequency, urgency, nocturia,

Detrusor sphincter dyssynergia: difficulty stopping urinary stream

constipation: > 30% of patients

Question 10

Multiple sclerosis diagnosis

Answer 10

no single diagnistic test:
Requires documentation of 2 or more episodes of symptoms
two or more pathological signs
symptoms > 24 hours
occur as distinct episodes
separated by month or more

Labs:
CBC, CMP, ESR, B12, ANA

MRI:
new focal white matter lesions
enhancing lesion
non-enhancing lesion in asymptotic location

CSF fluid
mononuclear cell pleocytosis
intrathecally synthesized IGG

Question 11

Multiple Sclerosis Treatment 3 categories

Answer 11

1. manage acute attacks
2. immune modulators and immune suppressive agents
3. symptomatic management

Question 12

multiple sclerosis management of acute attacks: rapid deterioration

Answer 12

consult neurology
methylprednisolone 500-1000 IV QD 305 days no taper

Question 13

Multiple Sclerosis immune modulators and suppressive agents

Answer 13

interferon or ocrelizumab

Question 14

Multiple sclerosis symptomatic management

Answer 14

bladder dysfunction: oxbutynin 5-15 mg po or detrol 2-4 mg QD

sphincter and detrusor dyssynergia :
terazosin 1-20 mg QD

Urinary tract infection: ABX treatment
increased PVR
Cranberry juice or Vit C
intermittent cath

Constipation:
High fiber diet and fluids

Depression:
Zoloft 50 mg PO QD

Daytime fatigue :
provigil 100-400mg QD